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Dramatically Reducing Sternal Wound Complications In Pediatric Cardiac Surgery: Beyond The Adult Guidelines
Muhammad Faateh, MBBS1, Zachary Corbin1, Lindsay Galchick1, Felicia S. Huang1, David S. Winlaw2, Kyle Riggs1, Marco Ricci1, Awais Ashfaq1, David L. S. Morales1, David G. Lehenbauer3.
1Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA, 2Department of Cardiothoracic Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA, 3University of Texas Southwestern Medical Center, Dallas, TX, USA.
Objective:Sternal wound complications(SWC) are associated with significant morbidity. Societal guidelines for prevention of SWC are notably absent for children. We implemented a SWC prevention-protocol by incorporating modern pediatric and adult scientific literature.
Methods:Consecutive pediatric index cardiac operations via sternotomy were evaluated before(01/2021-06/2023) and after(07/2023-07/2025) protocol implementation. The protocol included standard wound-closure technique, preoperative nasal screening/decolonization, chlorhexidine bathing, antibiotic prophylaxis, universal use of sternal vancomycin paste/avoidance of bone wax, supernumerary sternal wires, risk-based prophylactic negative-pressure wound therapy and antibiotic beads. SWC included dehiscence, superficial or deep surgical site infection(SSI) and were reviewed in STS and National Healthcare Safety Network databases.
Results:1,145 index cases were analyzed(592 pre, 553 post-protocol). High risk features for SWC were similar pre-vs-post-protocol.(Table) Dehiscence/SSI(composite) decreased from 4.9%(pre-protocol) to 1.5%(post-protocol), p=0.001. Complication specific rates pre-vs-post protocol were; dehiscence:2.9% vs 0.7%, p=0.006; deep-SSI:1.4% vs 0%, p=0.006; superficial-SSI:0.7% vs 0.7%, p=0.94. The greatest decline in the dehiscence/SSI(composite) was observed in neonatal/infant cardiac surgery from 2021-2025:10% (n=15) to 5.9%(n=8) to 4.4%(n=6) to 1.8%(n=3) to 2.8%(n=2), p=0.015. Overall, SSI in patients with prophylactic wound-vacs were significantly lower(0.5% vs 2.2%, p=0.019).
Conclusions: Implementation of a standardized protocol was associated with significant reductions in peri-operative SWC, notably eliminating deep-SSI. The greatest improvements were observed in neonatal/infant cardiac surgery. Future work should establish data-driven guidelines for reduction of SWC in children.
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